Provider Demographics
NPI:1578619383
Name:BATES, JUSTYNA
Entity Type:Individual
Prefix:MS
First Name:JUSTYNA
Middle Name:
Last Name:BATES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8411 MATHILDA AVE
Mailing Address - Street 2:
Mailing Address - City:AFFTON
Mailing Address - State:MO
Mailing Address - Zip Code:63123-3667
Mailing Address - Country:US
Mailing Address - Phone:314-481-4262
Mailing Address - Fax:
Practice Address - Street 1:121 KENRICK PLZ
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-4416
Practice Address - Country:US
Practice Address - Phone:314-898-0101
Practice Address - Fax:314-968-2954
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002131101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional